Tallahassee Memorial Healthcare (TMH) is a private, nonprofit community-based healthcare system that provides care to a 22-county region in North Florida and South Georgia. We are a career destination with over 6,000 colleagues who reflect the diversity of our community. 

TMH is the region's healthcare leader and top provider of advanced care with a 772-bed acute care hospital and the region's only:

• Level II Trauma Center 
• Primary Stroke Center 
• Level III Neonatal Intensive Care 
• Pediatric Intensive Care 
• The most advanced cancer, heart and vascular, orthopedic & surgery programs in the Panhandle. 

Our system also includes a psychiatric hospital, multiple specialty care centers, six residency programs and more than 50 affiliated physician practices. 

Your Role:

• Performs Minimum Data Set (MDS), case management, utilization review, quality assurance (QA), and discharge planning duties.
• Conducts federally mandated patient assessments based on Centers for Medicare and Medicaid Services (CMS) guidelines, including appropriate care planning, interdisciplinary communication, and Agency for Health Care Administration (AHCA) documentation preparation.
• Promotes wellness.
• Is responsible for collecting integral data and compiling/transmitting data to CMS.
• Determine patients’ needs based upon illness, diagnosis, prognosis, and social support systems.
• Contacts appropriate agencies to coordinate patient discharges into the community or long-term care settings.
• Ensures facility compliance with applicable state and federal regulation.
• Collaborates with other members of the healthcare team.

Reports To:

• Administrator, Rehabilitation Center (JC: 013501) [with delegation (as needed) to RN/Director, Rehabilitation (JC: 030101)]

Supervises:

• None

Required Education:

• Associate degree in nursing.

Preferred Education:

• Bachelor’s degree in nursing. 

Required Experience:

• One (1) year of relevant work experience.

Preferred Experience:

• Two (2) or more years of relevant work experience

Required Certification/License/Registry:

• Florida RN license.

Preferred Certification/License/Registry

• Minimal Data Set (MDS) certification or ability to obtain certification within one (1) year of employment.

Tallahassee Memorial HealthCare is an equal opportunity employer and drug-free workplace. All employment is contingent upon successful completion of a drug screen, background check, reference verification, health assessment, and credential/license verification.

Please remove the following from the Your Role section: 

• "Performs Minimum Data Set (MDS), case management, utilization review, quality assurance (QA), and discharge planning duties. "

Reports to under your role section is Manager for Case Management not Administrator, Rehabilitation Center (JC: 013501) [with delegation (as needed) to RN/Director, Rehabilitation (JC: 030101)

Please remove the following under the Preferred Certification/License/Registry section. That is not needed or used in this rrole.

• Minimal Data Set (MDS) certification or ability to obtain certification within one (1) year of employment.

Below is the Key responsibilities for this role: 

• Discharge Planning & Placement Coordination
  • Facilitate safe discharge placements to Inpatient Rehabilitation (IPR), Skilled Nursing Facilities (SNF), Long-Term Care (LTC), Assisted Living Facilities (ALF), and Independent Living settings.
• Home Health & Durable Medical Equipment Coordination
  • Arrange Home Health Care (HHC) services and Durable Medical Equipment (DME) directly from the Emergency Department.
• Transfers
  • Assist with documentation and coordination of hospital-to-hospital transfers.
• Medication Support
  • Provide patients with access to medication assistance programs and sign Letters of Agreement (LOAs) for medications when appropriate.
• Transportation Assistance
  • Coordinate discharge transportation for patients requiring support.
• Readmission Interventions
  • Meet with patients readmitted to the hospital within 30 days to assess contributing factors and develop prevention strategies.
  • Engage with patients who have visited the ER more than once within a six-month period to identify barriers and connect them with appropriate resources.
• Alternative Discharge Planning
  • Provide resources and coordinate safe discharge plans for patients presenting as social admissions, ensuring non-medical needs are appropriately addressed.